Risk perception and avoidance of preventive behavior on the COVID‐19 among cancer patients

Abstract Background and Aims Willingness to engage in preventive behaviors against coronavirus disease 2019 (COVID‐19) depends on people's risk perception. This is especially important in cancer patients who are at risk of complications from the disease. Therefore, this study was conducted to investigate avoidance of COVID‐19 preventive behavior of in cancer patients. Methods This cross‐sectional analytical study was done with 200 cancer patients who were selected by convenience sampling method. The study was conducted in Imam Khomeini Hospital of Ardabil, Iran from July to August 2020. A researcher‐made questionnaire was used to investigate the risk perception of cancer patients towards COVID‐19 with seven subscales according to the Extended Parallel Process Model. Data were analyzed by SPSS 20 using Pearson correlation and linear regression tests. Results The mean and standard deviation of the age of 200 participants (including 109 men and 91 women) was 48 ± 17. Results showed that the response efficacy (12.6 ± 2.2) had the highest mean and defensive avoidance (8 ± 2.8) had the lowest mean score among EPPM constructs. Linear regression results showed that fear (β = 0.242, p > 0.001), and perceived severity (β = 0.191, p = 0.008) were significant predictors of defensive avoidance. Conclusion Perceived severity and fear were significant predictors of defensive avoidance, and providing accurate and reliable news and information can be effective in reducing fear and promoting preventive behaviors.


| INTRODUCTION
A novel coronavirus was first reported in Wuhan, China in December 2019, and following its rapid spread, the World Health Organization declared coronavirus disease 2019 (COVID- 19) global health emergency in January 2020. 1,2 From the beginning of the disease outbreak, Iran was one of the countries with high number of patients and deaths caused by COVID-19 and faced many challenges in controlling the disease. 3 Worldwide studies have shown that the mortality rate of COVID-19 among hospitalized patients is 2%-5%, [4][5][6] while in Iran, according to the Ministry of Health reports, the mortality rate of hospitalized patients is up to 15%. 7,8 The high mortality rate among hospitalized COVID-19 patients is likely due to the presence of underlying chronic diseases in the general population. 9 COVID-19 is highly contagious and can be transmitted through aerosols, droplets and direct contact, and people with COVID-19 may also have latent symptoms for up to 14 days. 10 The highly contagious nature of disease threatens cancer patients, 11 because most patients are immunosuppressed due to the disease and its treatment. Cancer patients have higher rates of severe illness, ICU admission, and mortality after COVID-19 than the general population. 12,13 In Iranian culture, cancer patients usually expect their relatives to visit them.
This reduces social distancing and can increase the risk of contracting a novel coronavirus. 14 Attending the hospital for treatment and increasing the risk of covid-19 is one of the most important problems for cancer patients. 15 In the present study, it was somewhat differently from the previous studies and preventive behaviors were not investigated, but rather the effect of risk perception and efficacy appraisal on defensive avoidance in relation to protective behaviors of COVID-19 was investigated. Risk perception is one of the determinants of disease prevention and treatment, and studies have shown that in the case of COVID-19, risk perception has a significant relationship with compliance with preventive behaviors. 2,16,17 One of the most widely used models in the field of risk perception is the extended parallel process model (EPPM), 18,19 which is commonly used in health communication campaigns when a message is trying to persuade an audience to adopt a healthy behavior. 20 EPPM has seven constructs including perceived susceptibility, perceived severity, self-efficacy, response efficacy, fear, defensive avoidance, and protection motivation. According to the EPPM, feararousing messages may initiate two appraisals, (1) appraisal of the threat and (2) appraisal of the efficacy. The threat appraisal involves the severity and susceptibility to the risk. The efficacy appraisal also includes self-efficacy and response efficacy. In situations where appraisal efficacy is low, risk perception is not in a favorable state and fear overcomes both, defense mechanisms (defensive avoidance) are activated against healthy behavior. In such a situation, the possibility of protective motivation and perform preventive behavior decreases. 21 Considering the special problems of cancer patients, especially during the covid-19 pandemic, and the importance of risk perception in performing/not performing preventive behaviors against covid-19, the present study investigated the role of risk perception and efficacy appraisal on COVID-19 defensive avoidance in contrast to preventive behaviors in cancer patients.
The inclusion criteria were having cancer, and not being infected with COVID-19 at the time of the study. Data were collected using a researcher-made questionnaire on risk perception of cancer patients towards COVID-19 based on an extended parallel process model (EPPM). The process of data collection was done after explaining the objectives of the study and obtaining oral informed consent from the patients.

| Measurements and scoring
The questionnaire consisted of three parts: 16

| Regression results
In the regression model, R squared (R 2 ), and adjusted R squared (adj-R 2 ) were 0.282 and 0.28, respectively, according to which, about 28% of the changes in the defensive avoidance behaviors explained by significant dependent variables ( Table 3). Fear in the present study was significant strongest predictor of defensive avoidance in cancer patients. Some studies have shown that people with underlying medical conditions report more fear of COVID-19. 26 Qian et al. 27 in China also found that higher COVID-19

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risk perception was associated with increased fear and anxiety.
Musche et al. 28 in Germany also showed that diabetic patients had a greater risk perception and fear of COVID-19 than the general population.
Some studies, however, have dealt with the issue from another aspect. They have shown that high risk perception is not always associated with positive results and sometimes leads to increased fear and adoption of defensive and avoidance behaviors.
For example, a study showed that the risk perception of the epidemic disease is related to different perceptions, which can be referred to the reduction of fear or the exaggeration of the risk around COVID-19. 29 The results of a qualitative study by Alqahtani et al. 30 in Saudi Arabia also showed that risk perception is the basis of the tendency to deny risks or react with exaggeration in terms of precautionary reactions related to COVID-19. This is a vicious cycle because the higher risk perception of contracting COVID-19 can lead to an increase in anxiety and fear of chronic patients and subsequently cause postponement of treatment sessions and increase in avoidance behaviors. 16 T A B L E 3 Regression analysis of EPPM constructs for COVID-19.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data generated or analyzed during this study are included in this article and can be requested from the corresponding author.

TRANSPARENCY STATEMENT
The lead author Sajjad Narimani affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.